Vinci Ho

I do not think it is fair to say BMA/GPC had done absolutely nothing to ‘help’ . In effect , any changes brought forward at this dire stage of general practice , can be criticised as useless . I understand that some might even fancy some kind of ‘scorched earth’ politics to wipe out and withdraw from this current model of NHS general practice. Reality is somewhere in the middle between the two extremes.
One thing for sure to me is , this 5 year ‘deal’ should be judged subjectively and objectively( hence , evidently) on survival , not ‘glory’ , of general practice. We need people to stay as well as to come in this career . If survival is victory, this is how we judge its success . If British politics is at its all time low (because of you know what ), so is our profession. Perhaps , live or let die , BMA/GPC knows very well , deep down , that this is the ‘last chance’.......

One thing these think tank academics has to realise that the reason why General Practice in NHS is so vital , was because it is a ‘dumping ground’ for all other sectors of health and social care . How often have they heard this sound bite , ‘ Oh ! Go back to see your GP’ . In a way , it is a comfortable endpoint for those in hospitals and social care if they want to wash their hands at some points.
At least , GPs are still doctors. Would they be happy to say in the future , ‘ Oh ! Go back to see your physician assistants etc ?’😶😅

I do not think it is fair to say BMA/GPC had done absolutely nothing to ‘help’ . In effect , any changes brought forward at this dire stage of general practice , can be criticised as useless . I understand that some might even fancy some kind of ‘scorched earth’ politics to wipe out and withdraw from this current model of NHS general practice. Reality is somewhere in the middle between the two extremes.
One thing for sure to me is , this 5 year ‘deal’ should be judged subjectively and objectively( hence , evidently) on survival , not ‘glory’ , of general practice. We need people to stay as well as to come in this career . If survival is victory, this is how we judge its success . If British politics is at its all time low (because of you know what ), so is our profession. Perhaps , live or let die , BMA/GPC knows very well , deep down , that this is the ‘last chance’.......

I see potential caveat of (a) opposing for the sake of opposition and dissatisfaction of the current vignette of misery (b) swinging the pendulum from one extreme to the other (c) fitting one size to all .

All these times , we are debating merely about the nature and substance of this GP training programme which , in the perspective of lifetime ongoing education , represents only a small part in my opinion .
Politics, economics(hence , management )and hard core medical knowledge are , in fact , converging to one entity of expertise in a rather unique system like NHS general practice. The education has to be continuing consistently after the 3, 4 or 5 years of so called fundamental training . Instead , I see colleagues falling off a high cliff free-falling after this training period with much less guidance ( certainly not NICE guidances!) which direction they should go . Appraisals , these days , are plainly serving the purpose of rubberstamping for revalidation at the end of a five year period . As I always stress , expertise is one of the four resources vital to us and am rather disappointed of the shortsightedness in how we should train careee general practitioners.......

Sigh！ Same old slippery slope fallacy.
When you are starved at the level of getting enough bread and butter every day , there is no place for fancying to have steak on the table .
Yes , perfect , ideal general practice perhaps , could be like this but what is the reality?
Also , you have to remember what the agenda of the government was when the previous Health Secretary pushed this policy forward, quite rightly eroding the GP’s time (a valuable resource) when continuity of care is like dinosaur facing historical extinction.
Ultimately, the government only cared about cutting costs and it was exactly this reason why it fell down the slope in the fiasco of Capita promising better with less cost .
For these academics, please come down the tower and join us in this battle against the government and its technocrats.

I think the government and NHSE have a choice to make . If they refuse to ditch this culture of top-down control through initially CCGs ( now GP networks) , more GPs will leave in an even shorter space of time ahead ,as well as much less young blood joining into the frontline to deliver services .
As your previous editorials commented , this contract has not really revealed tangible solutions to the enormous workload ( both necessary and unnecessary) GPs facing everyday . The intentions of the government to ‘value’ GPs in this contract remain only ostentatious . In fact , the overall workload might eventually increase instead .
Alongside with contentious issues of state-backed indemnity scheme , fiasco of Capita in GP support services and pension collections and the stifling arrangement of personal tax allowances versus pension contributions, NHSE and the government are long way from drawing a truce with us . Comparatively , we cannot be as intransigent as EU in terms striking a proper ‘deal’ . But what the hell , I suppose nobody dares to say that the government needs us even more than EU?!

Remember when CCG ideology first came out ? CCGs are GPs and GPs are CCGs , by default. And then?
Ultimately, it is not about who or what is ,so called , leading. If that leadership is merely another layer of top-down control by NHSE , the same slippery slope fallacy is repeating itself .
Nakita , after the Madangate ( if you know what I am talking about ) , the trust of GPs on NHSE was right at the bottom. I hope you can understand while we probably would like to give you the benefit of doubt in this ‘honeymoon period’.

Pros and cons
Clearly , it is logical to remove the target as our A/E colleagues are equally under immense pressure to fulfil these bureaucratic requirements. Whatever new priorities mean , however , is at risk to shuffle those patients with presumed ‘minor’ problems somewhere to wait longer and longer.
End of the days , you cannot cover ten cups with only eight lids . GPs ( and the future networks) are to bear the overflow.

I think all these minor injury units( and walk-in centres) are all at risk of CCGs’ closure decisions. It was ,perhaps, always a consideration amongst these commissioners in CCGs for cutting cost to balance the stifling budgets set by our friend,NHS England ( aka Ministry of Plenty) . At least , the opening hours were to be reduced.
You see , if the four-hour A/E target is to end ( replaced by whatever so called new priorities) , people with presumed minor injuries can just sit in A/E for long time ( or eventually walk away). Hospitals do not need to worry about penalty for not meeting the target anymore . In fact , there is no political pressure or urgency to sort out this cohort of patients. May well just close all these minor injury units in the community to save money , ha ha ha (laugh from Lucifer ).

You see
Sometimes I just think these researchers need to think outside the box before undergoing and reporting certain ‘researches’ . Did this report help anything to our reality ; a hostile environment for GPs with recruitment and retention crisis , disproportionate rise in patients’ demands , poor and ignorant leadership from technocrats/ politicians etc (list goes on).
Remember the infamous story of Agent Hunt exploiting BMJ’s study of more deaths were reported in hospitals in weekends than in week days ? And now BMJ has become a lot politically charged these days!
I know academics do not like or even care politics ( none of us do) but it is like, ‘think carefully before you open our gob’ with a bit more political wisdom , please .

You should know me , by now , my background ( if you read my old comments). Yes , I have ‘conflict of interest’ simply because I am a frontline senior GP partner, ha ha ha .
Seriously,
(1) As I wrote in the past , the 2010 NICE guidance had drastically changed my way of managing hypertension. And I cannot deny the evidence on hypertension accumulated ,since then, is pointing towards the lower the target, the less morbidity and mortality. The old saying for patients with advanced CKD was ‘ lower the BP until they just about to drop!’ stands. So with organ damages , diabetes , CKD , I don’t think we should argue too much .
(2) Questions remain on this ‘shady’ insurance broker’s tool-like instruments called CVD risk calculator(s) . Nobody wants to publicly debate their accuracy and reliability . We seem to have one calculator pushed out after another . Now we have heart age calculator(s) as well . If I accept the argument that generic anti-hypertensives are actually cheap( hence , the conspiracy of more profits for pharmaceutical companies does not sustain , the companies creating and maintaining these calculatiors are more than euphoric for this new NICE guidance on hypertension.
(3) And because of this issue of calculators( with more to come) , we have the argument of ‘Over-diagnosis’ . I am glad that we have already started debating this subject sensibly and logically in many platforms, here and BMJ , for instance. Our discussions on this matter will provide the ‘backstop’ ( started to like this word , ha ha ha) for a relentless belief that more diagnoses and their treatments are better for people’ health.
(4) Then it comes to resources especially time and expertise. I would argue that unless these new scientific ideologies( remember we have NICE controversies in asthma , COPD , diabetes previously) are incorporated into our GP contract discussions in NHS , NICE will remain out of touch with all its ‘experts’ locked up in the top floor of the Ivory Tower . Please do not tell us that these will be negotiated and implemented ‘successfully’ at the level of GP networking !
(5) Last , but certainly not the least , I can see the seven-day GP opening protagonists ,as well as smartphone-AI- GP by hand-Robocop fanatics , to reinvigorate the argument that more GP access ,by any means , will improve the nation’s health . If you want to convert a FORD Fiesta into a Volvo or BMW , it is not just about changing the outside cover without real-time investment into the interior engines . Common sense .

Ice frozen deep down to three feet is never caused by one day freeze .
The question is :what are the reasons for this historical low in attendance? We all know the cuts made to PHE budget are substantial. Alongside with other public health issues , is this only a tip of an iceberg? Who should be held accountable ?? Nobody??

The other spin-off from this ‘phenomenon’ is in fact , rises in complaints and litigations . Hence , indemnity goes up . GPs continue to exit the door while young ones see the no-go sign .Fine, the state indemnity comes in for GP . But in front of potentially hefty compensation claim bills , which side will the government and its technocrats stand ? Let GPs hanging out dry is an ‘option’ ?
The vicious cycle goes around. It traces back to the fact that there are not enough ‘tools’ to work with in primary care: Workforce , Expertise , Time , Space and of course , Funding.
The government must succumb to humility and face the truth that the system is no longer safe enough . Actions are for now not later .........

Nobody should be surprised here . Every matter has its roots and tails and every incident has its beginning and ending.
The question is whether the government really cares about these declining figures(including those in secondary care)or more precisely, does it know how to care?

It is ultimately about whether you believe in this ‘new’ contract.
But I will always say ,’ The truth cannot be condemned to be a lie and a lie can never be disguised as the truth.’
For those up in the hierarchy, remember this :
‘’You can fool all the people some of the time, and some of the people all the time, but you cannot fool all the people all the time. ‘’
Abraham Lincoln